Mechanisms for the Clinical Utility of Low-Frequency Stimulation in Neuromodulation of the Dorsal Root Ganglion

Chapman, Kenneth B.; Yousef, Tariq; Foster, Allison; Stanton‐Hicks, Michael; Helmond, Noud van

doi:10.1111/ner.13323

Cited by 34 publications

(29 citation statements)

References 83 publications

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“…PPT testing evokes pain from deep soft tissues and thus represents a test method pertaining to the mechanical Aδ‐ and C‐fiber‐mediated 56 component of CLBP. We found that DRG‐S raises PPT in the painful area of the low back in CLBP patients, consistent with the presumed inhibition of nociceptive input with DRG‐S 26,57 . The neuropathic component of CLBP may present as areas of numbness with decreased mechanoreceptive and proprioceptive perception 5–8 .…”

Section: Discussionsupporting

confidence: 74%

Dorsal Root Ganglion Stimulation Normalizes Measures of Pain Processing in Patients with Chronic Low‐Back Pain: A Prospective Pilot Study using Quantitative Sensory Testing

et al. 2021

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Background Dorsal root ganglion stimulation (DRG‐S) is used as a treatment for chronic low‐back pain (CLBP), although its underlying mechanisms remain elusive. CLBP patients have been found to have reduced mechanoreceptive perception, reduced endogenous analgesia, as well as deep‐tissue hyperalgesia when compared with healthy controls. Using quantitative sensory testing (QST), we studied if DRG‐S in CLBP patients results in changes in pain processing. Methods Quantitative sensory testing was performed in patients before trial implantation of a DRG‐S system for CLBP and just before the trial lead removal or at 1‐month follow‐up after the permanent implant. We determined the pressure pain threshold (PPT) and mechanical detection threshold (MDT) at the most painful lower‐back location. PPT was also measured on the contralateral shoulder as a control. We obtained a measure of endogenous inhibitory pain modulation using conditioned pain modulation (CPM). Results We enrolled 11 patients (60 ± 16 years). Pain decreased from 8.5 ± 1.0 at baseline to 2.0 ± 1.5 on a 0‐10 numerical rating scale with DRG‐S (P < 0.01). From baseline to with DRG‐S, PPT on the most painful location on the low back increased from 28.7 ± 13.6 to 43.4 ± 17.2 N/cm2 (P < 0.01). MDT on the same location decreased from 8.1 ± 10.4 to 3.4 ± 4.7 mN (P = 0.07). PPT on the control location and CPM did not change significantly. Conclusions Our results suggest that DRG‐S in CLBP patients reduces deep‐tissue hyperalgesia in the low back, while improving mechanoreceptive perception. These changes in both neuropathic and nociceptive components of CLBP were accompanied by clinical improvements in pain and function.

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Section: Discussionsupporting

confidence: 74%

Dorsal Root Ganglion Stimulation Normalizes Measures of Pain Processing in Patients with Chronic Low‐Back Pain: A Prospective Pilot Study using Quantitative Sensory Testing

et al. 2021

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“…In the physiologic state, LTMRs typically fire at frequencies of 0.5–5 Hz (24‐26); in vitro studies showed that applying very low‐frequency stimulation to primary afferent neurons at the DRG or the dorsal root reduces excitatory output in the superficial dorsal horn (25‐27). These converging lines of published evidence suggest that a key mechanism of action for DRG‐S is the preferential recruitment of LTMR fibers at very low frequencies to modulate pain transmission through endorphin‐mediated inhibition (18,28).…”

Section: Introductionmentioning

confidence: 99%

Very Low Frequencies Maintain Pain Relief From Dorsal Root Ganglion Stimulation: An Evaluation of Dorsal Root Ganglion Neurostimulation Frequency Tapering

Chapman

Yousef

Vissers

et al. 2021

Neuromodulation: Technology at the Neural Interface

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“…Through diverse and unique mechanisms of action, DRG-S is being effectively applied in a variety of "off label" pain syndromes. [23][24][25][26][27][28][29] As such, there is an impetus to limit complications, such as lead migration, lead fracture, and the concerns over revision surgery, as these issues have the potential to reduce the therapeutic value of DRG-S to patients. The introduction of the novel paramedian, ipsilateral lead placement technique described in this article for DRG-S implantation seeks to further minimize complications, particularly lead fracture, through leveraging the shared experience and developed techniques of the authors.…”

Section: Discussionmentioning

confidence: 99%

A paramedian approach for dorsal root ganglion stimulation placement developed to limit lead migration and fracture

et al. 2021

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Introduction: Dorsal root ganglion stimulation (DRG-S), has demonstrated superiority in the treatment of complex regional pain syndrome and causalgia. Lead migration and fracture impact DRG-S therapeutic stability. Lead anchoring reduces DRG-S lead migration without increasing lead fracture. Lead fracture may be related to lead entrapment in the superficial fascial plane. A novel medialized approach for lead placement and anchoring is presented to address these issues. Methods:We suggest an alternative technique for implanting percutaneous DRG-S leads at the T10-L5 levels.Results: A novel medialized ipsilateral technique for lead placement and anchoring for single, bilateral, and adjacent segment placement is presented. The Tuohy needle puncture site is medial to the pedicle and adjacent to the spinous process, two vertebral levels caudad to the target foramen. Trajectory is maintained in the sagittal plane, to access the caudad interlaminar space near the midline. This technique allows for ipsilateral or contralateral lead placement. After epidural access, the introducer sheath is rotated toward the targeted foramen and advanced. The guidewire followed by the lead is passed, and once lead position is confirmed, tension "S" loops are created, followed by anchoring to the deep fascia. Conclusion:We describe a new paramedian technique for DRG-S lead placement.We propose it will decrease DRG-S complication rates through anchoring to reduce migration and by avoiding the fascial planes thought to be responsible for fracture. Long-term outcomes applying our proposed techniques are required for determining the true impact, however, early anecdotal results suggest that these new techniques are favorable.

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Mechanisms for the Clinical Utility of Low-Frequency Stimulation in Neuromodulation of the Dorsal Root Ganglion

Cited by 34 publications

References 83 publications

Dorsal Root Ganglion Stimulation Normalizes Measures of Pain Processing in Patients with Chronic Low‐Back Pain: A Prospective Pilot Study using Quantitative Sensory Testing

Dorsal Root Ganglion Stimulation Normalizes Measures of Pain Processing in Patients with Chronic Low‐Back Pain: A Prospective Pilot Study using Quantitative Sensory Testing

Very Low Frequencies Maintain Pain Relief From Dorsal Root Ganglion Stimulation: An Evaluation of Dorsal Root Ganglion Neurostimulation Frequency Tapering

A paramedian approach for dorsal root ganglion stimulation placement developed to limit lead migration and fracture

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